Achieving Simplicity in a Complex World of Safety

Effective leaders deliver simplicity in response to complexity. (Harter, 2006, p. 77)

Although anyone can be a leader in any given context (expert, coach, etc.), the head of the organization serves as a unifying symbol that represents the collective commitment for action. One of the ways the person at the top can convert complexity and chaos to simplicity is to implement a state-of-the-art safety management system.

“So how are we doing?”
These platforms provide easy-to-use tools and simplified dashboards that indicate the status of “required read” communications, hazard monitoring and risk levels across the entire organization. They also make filing forms easy from mobile devices so all personnel are more likely to participate via the click of an icon. And because the Accountable Executive must be aware of and accept (or not) the residual safety risks of the operation, these systems provide for efficient presentation, coordination and approval of all key safety risks, removing the guesswork related to the question, “So how are we doing?”.

To demonstrate how a software system converts complexity to simplicity, let’s examine the life cycle of a hazard in an organization that was processed by superbly-designed Safety Management System (SMS) software and well-trained staff. Let’s say the pilots debriefed a flight using their portable smart devices to enter an occurrence, i.e., a severe nose-wheel vibration on landing. In ten minutes, the pilots captured what went right, what didn’t go so well, how they could improve and properly coded the occurrence in the system for future tracking. The system immediately notified the Safety Manager (SM) of the occurrence.

The SM followed the steps on the form to determine the associated root cause and hazard. In this case, the pilots deployed the thrust reversers at the same time the nose-wheel was touching down. The less than perfectly synchronous deployment of the thrust reversers resulted in the nose-wheel contacting the runway with a glancing blow, resulting in severe vibration. The hazard was determined to be “SOP Non-compliance” due to error as the pilot flying was relatively inexperienced with this type of aircraft.

The SM added the Chief Pilot to the safety report, and the Chief Pilot sent a safety bulletin via the system to all pilots to read before their next flight, reminding them to only deploy the thrust reversers after the nose-wheel makes positive contact with the runway. The system tracked the percentage of the pilots that read the bulletin, and specifically listed who read and did not read the bulletin.

Converting Complexity to Simplicity
The safety report was included in the next safety meeting and the committee determined the mitigation should include revised emphasis on this specific SOP in the pilot training program, to include a revision to the pilot training syllabus. The safety meeting minutes were captured in the system for future review. The Chief Pilot used the software system to revise the training syllabus, one of the many documents managed by the system. The revision suggestion was posted in the system and approved by the safety committee. The new revision of the training syllabus was then issued by the system and a message was automatically sent to all applicable personnel.

The Safety Committee also determined that this occurrence was worthy of monitoring and a safety performance indicator was created in the system to track the effectiveness of the mitigation effort, i.e., awareness (via bulletin) and enhanced training. The hazard risk register was updated via the safety report to indicate the hazard being monitored, the applied mitigation, the initial risk level and post mitigation risk level. The system automatically updated the safety risk profile from the hazard risk register so management could see the landscape of initial risk versus final risks after mitigation in specific categories related to the operation.

The safety risk profile represents the organization’s theoretic safety performance. Actual safety performance is monitored via the safety performance indicators and targets which were created by the SM within the system. After a reasonable time of monitoring the hazard via the safety performance indicator, the mitigation was deemed to be effective by the safety committee. Therefore, this specific SOP related hazard was closed on the hazard risk register, yet the safety committee decided to continue tracking all SOP non-compliance via a safety performance indicator provided by the system and captured via the post-mission debrief tool.

With all this complexity converted to simplicity, any member of the organization, to include the Accountable Executive, can review the safety risk profile and hazard-risk registry and be thoroughly aware of the operational risks. The preceding example is a high-level overview of some of the fundamental steps of SMS that can seem quite complex and overwhelming. To effectively manage safety risks, your organization should be equipped with the right tools and training.

Reference
Harter, N. (2006). Leadership as the promise of simplification. Emergence: Complexity & Organization, 8(4), 77-87. Retrieved from http://emergentpublications.com/eco/ECO_papers/Issue_8_4_8_PH.pdf